Consent Forms
Consent for Services
Shore Therapy Services
Required
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I authorize Shore Therapy Services to render appropriate evaluation and therapy services to the client named below in accordance with state and federal laws. I understand that care will be provided by a qualified, licensed, and trained health professional. I recognize, agree and understand that I have the right to refuse treatment or terminate services at any time by Shore Therapy Services in writing. By checking this box, I declare I am not a beneficiary of and Medicare services. In addition, Shore Therapy Services may terminate services by notifying me in writing
I do not give my consent or am withdrawing my consent regarding Shore Therapy Services rendering evaluation and therapy services to the client named below.
Name of Client:
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First Name
Last Name
Client's Date of Birth:
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Year
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Today's Date
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Signature of Client or Legal Representative:
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Relationship to client:
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Self
Parent/guardian
Spouse
Other
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Payment Policy
Thank you for choosing our private practice to serve you. We are committed to providing you with the highest quality care. Please know that the timely payment of your bill is an integral part of our service and as such, this payment policy is an agreement between you and Shore Therapy Services for payment of services provided. By signing this policy, you are agreeing to pay for services provided to you or your family member. As a client of Shore Therapy Services, you are required to carefully review and sign our payment policy.Please read the following information carefully:All therapy fees (including session fees and/or co-pays, if applicable) are due at the time of service.We accept the following payment methods at this time: Credit, Cash, or Check. Checks should be made payable to: Shore Therapy Services. We will provide you with an invoice outlining the services rendered and the amount charged. Please read to acknowledge understanding and the sign below:
Name of Client:
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First Name
Last Name
Client's Date of Birth:
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1. Required:
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I understand that I am responsible for all costs / fees that any third-party payer (ex.insurance company, private school, etc.) does not cover. In the event that a third-party payer source determines that rendered therapy services are “not covered” or otherwise denied, I will be responsible for all outstanding charges. I understand that I will be billed accordingly and will be responsible for immediate payment. I also understand thatShore Therapy Services will not become involved in disputes between you and your third-part source regarding uncovered charges or reasons for denial
2. Required:
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I understand that if fees are not paid in full, treatment sessions may be postponed or cancelled until payment is received.
3. Required:
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I understand that all returned checks will be subject to a $25.00 returned check fee.Charges incurred and not paid after 90 days may be turned over to a collection agency at the client’s expense. Overdue accounts may also be reported to a Credit Bureau.
4. Required:
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I understand that I am responsible for all legal and collection fees, which Shore Therapy Services may incur if payment is not made in accordance with the terms and conditions herein.
5. Required:
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I understand that refunds will be issued only in instances of overpayment. All refunds will be processed within 60 days after the overpayment is discovered on the client’s billor at the time the refund is requested. Refunds for payments made with a credit card will be credited back to the credit card used, all other refunds will be issued by a check. Clients who used a third-party source will not be issued a refund until full payment is received from the appropriate source.
6. Required:
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I understand that all cancellations require 24 hours’ notice and that there will be a $25.00 charge for any cancellations made less than 24 hours. This charge is my sole responsibility and will not be covered by a third-party source.
7. Required:
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I understand the payment policy and the risks of not adhering to it.
Today's Date:
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Signature
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Relationship to client:
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Self
Parent/guardian
Spouse
Other
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General Acknowledgment of Forms
I hereby acknowledge and agree that I read all of the forms and documents provided to me in connection with the evaluation and treatment provided by Shore Therapy Services and/or their employees.I fully understand the meaning and intent of the forms provided and I agree to all content included.I have been given an opportunity to ask questions about the forms provided. All my questions have been answered to my satisfaction byShore Therapy Services.
Name of Client
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First Name
Last Name
Client's Date of Birth:
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Month
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Day
Year
Date
Signature of Client or Legal Representative:
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Today's Date:
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Month
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Day
Year
Date
Relationship to client:
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Self
Parent/guardian
Spouse
Other
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Acknowledgement That You Have Received Our HIPAA Privacy Notice
Shore Therapy Services, LLC is required by law to protect the confidentiality of your health information and records. This information may include:Notes from your doctor, teacher, or other healthcare providersMedical historyTest resultsTreatment notesInsurance informationAs a requirement, we provide you with a copy of our privacy notice, which outlines how your health information may be used and shared.By signing below, I acknowledge that:I have received a copy of the Shore Therapy Services HIPAA Notice of Privacy Practices, which thoroughly explains the uses and disclosures they may make with respect to my individually identifiable health information.I have had the opportunity to read the notice and have any questions regarding its content answered to my satisfaction.I understand that Shore Therapy Services is prohibited from disclosing my health information except as specified in the notice.I am aware that Shore Therapy Services reserves the right to modify the notice and the practices described within, provided they send a revised notice to the address I have provided.
Name of Client:
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First Name
Last Name
Client's date of Birth:
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Month
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Day
Year
Date
Signature of Client or Legal Representative:
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Today's Date:
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Month
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Day
Year
Date
Relationship to client:
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Self
Parent/guardian
Spouse
Other
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Attendance/Cancellation Policy
Attendance and participation in therapy along with complete compliance with any associated home programs are essential for therapeutic success. While Shore Therapy Services understands that illnesses and emergencies occur, we respectfully request that you avoid frequent cancellations or “no shows”. Please adhere to our following policy regarding providing our office with advance notification for any cancellations resulting from a conflicting appointment, vacation, or any other event.All cancellations must be submitted 24 hours prior to your scheduled appointment.A fee of $25.00 may be assessed if the following occurs. This fee will be billed directly to the client and not their health insurance company, as medical insurance does not provide coverage for missed sessions.• If cancellations are made less than the required 24 hours.• If the client fails to show up for a scheduled appointment.If you miss / reschedule / are late for 3 scheduled appointments, the office reserves the right to discharge the client. Additionally, if you arrive late for a scheduled appointment, the session will still end at the scheduled time or may be cancelled.I understand the attendance / cancellation policy and the risks of not adhering to it.
Client's Name:
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First Name
Last Name
Today's Date:
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Month
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Year
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Signature
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Relationship to client
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Self
Parent/guardian
Spouse
Other
Submit
Submit
Should be Empty: